Mylan?l

Seeing
is believing

CERTIFICATION FORM:
EpiPen? (epinephrine infection) Auto-Injector 
Program

The school and/or school district identified below (the "School") hereby acknowledges and agrees that the EpiPen?
(epinephrine injection) Auto?Injectors School Discount Program made available by Mylan Specialty L.P. (?Myian
Specialty?) to the School is because it is a school and is conditioned upon the undersigned making this certification to
Mylan Specialty.

The School represents and warrants to Mylan Specialty that:


(ii)


(iv)

all of the information provided in this certification is true, complete and accurate;

the School will only receivelpurchase EpiPen? (epinephrine injection) 0.3mg and EpiPen Jr? (epinephrine
injection) 0.15mg Auto?injectors in accordance with all applicable laws for use by the School, and the
School has presented a valid prescription for the product;

the School is an entity whose primary purpose is education for students in grades through 12 that is
licensed as an educational facility under all applicable laws;

the School shall make best efforts to provide appropriate product training to any School personnel who may
administer an EpiPen? or EpiPen Jr? Auto-injector;

the person signing this certification on behalf of the School has the requisite authority to make this
certification on behalf of the School identified below;

the School hereby certifies that it will not in the next twelve (12) months purchase any products that are
competitive products to EpiPen? Auto-injectors;

the School shall only purchase EpiPen? Auto-Injectors for its own use and the School shall not sell or
transfer any EpiPen? Auto-injectors purchased at the discounted price to a non-school third party, unless
the prior written approval of Mylan Specialty, in its sole discretion. is obtained;

any transfer of any quantity of EpiPen? Auto-Injectors purchased at the discounted price available to the
School in violation of this certification will be considered a breach of this certification allowing Mylan
Specialty to prohibit the School from purchasing EpiPen? Auto-Injectors at the discounted price available to
schools; and

the School agrees to Mylan Specialty's use of the School's name for promotional purposes.

To order EpiPen 2-Pak? and EpiPen Jr 2-Pak? cartons at a discounted price,
please fill out and submit the order form below:

 

EpiPen? Auto-lniector Cartons at

Quantity (2?Pak Discounted Price Per Carton

 

 

 

 

Discounted Price Cartons) 0rdered* (One Carton 2 Auto-injectors) Total
EpiPen?2-Pak? $112.10
EpiPen Jr 2?F'alt? $112.10
Total Quantity Ordered" $112.10

 

 

 

 

 

La] Please check if you would like to receive periodic updates about this program or EpiPen? Auto-Injector.

*Please note there are two auto-injectors per EpiPen 2?Pak? or EpiPen Jr 2?Pal<?. Example: If you wish to order 2
EpiPen? Auto?Injectors and 2 EpiPen Jr? Auto?Injectors, put the number 1 in the Quantity Ordered box next to EpiPen
2-Palr? and 1 in the Quantity Ordered box next to EpiPen Jr 2-Palr?. It you wish to order 4 EpiPen Jr? Auto-Injectors,
put the number 2 in the Quantity Ordered box next to EpiPen Jr 2-Pak@ and 0 (zero) in the Quantity Ordered box next
to EpiPen 2-Pak?.

7L ORDERING FOR MULTIPLE SCHOOLS: If you are ordering for multiple schools within a single school district, you
may order unlimited two 2-Palr? cartons per school. For example, if you are ordering two EpiPen Jr 2-Palt?) cartons
for each of 10 schools, you should enter 20 in the Quantity Ordered column next to EpiPen Jr cartons.

If the terms and conditions provided in this certification are amended, modified or altered in any way, it will be considered

null and void.

 

School/School District Name:

 

 

School Address:

 

City/StatelZip:

 

 



Updated June 2015

 

 

SchooiPhone:
Authorized Schooi Signatory Name:

 

 

Authorized School Signatory Title:

 

Authorized School Signatory Emaii:
Signature: Date:

 

 

 

 

 

Please fax the completed Certification Form and a copy of a vaiid EpiPen? Auto-injector prescription for the total
number of EpiPen? Auto-injectors ordered to BioRidge Pharma, LLC

Attn: Kristina Paich
Fax: 973~718-4328 or email/scan to: info@bioridgepharma.com
Phone: 973-845-7600

indications

EpiPen? (epinephrine injection) 0.3 mg and EpiPen Jr? (epinephrine injection) 0.15 mg Auto-Injectors are for the
emergency treatment of life?threatening ailergic reactions (anaphyiaxis) caused by allergens, exercise, or unknown
triggers; and for peopie who are at increased risk for these reactions. EpiPen? and EpiPen Jr? are intended for immediate
administration as emergency supportive therapy only. Seek immediate emergency medical help right away.

important Safety information

EpiPen? and EpiPen Jr? Auto?Injectors contain a single dose of epinephrine, which you (or your caregiver or others who
may be in a position to administer EpiPen? or EpiPen Jr?) inject into the middle of your outer thigh (upper leg) (through
clothing, if necessary). Get emergency medicai heip right away. You may need further medical attention. Only a health
care professional should give additional doses of epinephrine if you need more than two injections for a single
anaphyiaotic episode. DO NOT YOUR VEINS, BUTTOCKS, FINGERS, TOES, HANDS OR FEET. in case
of accidental injection, please seek immediate medicai treatment. Epinephrine should be used with caution if you have
heart disease or are taking certain medicines that can cause heart?related (cardiac) 

Tell your doctor if you have certain medical conditions such as asthma, depression, thyroid disease, Parkinson?s disease,
diabetes, high blood pressure or heart disease, have any other medical conditions, are pregnant or plan to become
pregnant, or are breastfeeding or plan to breastfeed. Be sure to also teii your doctor ail the medicines you take, especially
medicines for asthma. If you have certain medicai conditions, or take certain medicines, your condition may get
worse or you may have ionger lasting side effects when you use EpiPen? or EpiPen Jr?.

The most common side effects may include increase in heart rate, stronger or irregular heartbeat, sweating, nausea or
vomiting, difficulty breathing, paieness, dizziness, weakness, shakiness, headache, apprehension, nervousness or
anxiety. These side effects may go away if you rest. Teli your heatth care professional if you have any side effect that
bothers you or that does not go away.

Piease see the full Prescribing information and Patient information.

You are encouraged to report negative side effects of prescription drugs to the FDA.

Visit or cail 

For additional information, piease contact us at 800-395?3376.

EpiPen?, EpiPen Jr?, EpiPen 2-Pak? and EpiPen Jr 2-Pak? are reggstered trademarks of Myian Inc. licensed exciusiveiy to
its whoily-owned subsidiary, Mylan Specialty L.P. EpiPen4Schools is a registered trademark of Myian inc.

2015 lViyian Speciaity LP. All rights reserved.


Updated June 2015